Outline. Eco-social model of health Environmental factors

Transcription

1 Health and the Environment: A Call to Action Ted Schettler MD, MPH CHA Webinar Oct. 6, 2010 Outline Eco-social model of health Environmental factors Environmental chemicals/pollutants Diet/nutrition Built environment Psychosocial environment Challenges: aggregate exposures, cumulative impacts Responses; opportunities 1

2 Eco-social model of health determinants individualfamily- communitysocietal-level variables genes Housing Economic status Stress Access to health care Social support Nutrition Toxic chemicals Environmental pollution Radiation Infections Physical agents physical, social, biologic environment An eco-social health framework: the individual in the context of family, community, society and ecosystem. 2

3 The eco-social health framework extended to the subcellular level. Individual Organ system Cell Organelle Cell Signaling Unique windows of vulnerability TOXICANTS INFECTIONS NUTRITION NUTRITION GENETICS Childhood health, illness SOCIAL ENVIRONMENT? Adult health, illness Cardiovascular disease Diabetes Cancer Neurodegenerative disease Etc. 3

4 Early life experiences can influence later-life health, disease Toxic exposures (e.g. air pollution, pesticides) Diet Stress Obesity, hypertension, cardiovascular disease, diabetes Alzheimer s, dementia Birth weight; development Aging begins at conception Exposures to environmental chemicals are common CDC: Reports on levels of 212 chemicals in a representative sample of the US population 4

5 Environmental Working Group; random specimens of cord blood Body burden: the pollution in newborns Tested for 413 chemicals Tested for 413 chemicals 287 chemicals detected; 200 average Carcinogens, Developmental toxicants Birth weight Birth defects Impaired neurodevelopment, etc. Impacts of this mixture unstudied and unknown 5

6 Manifestations of abnormal development Fetal death Low birth weight; e.g. maternal smoking, air pollution, some pesticides Birth defects; e.g., pesticides, solvents Cancer; leukemia and maternal pesticide exposures, paternal exposure to carcinogens Functional abnormalities; e.g., neurodevelopment; reproductive, immune, respiratory, and cardiovascular systems, etc. Increased susceptibility to adult disease Neurodevelopmental problems Nearly 17% of children under age 18 in the US Nearly 17% of children under age 18 in the US suffer from one or more developmental disabilities Learning disabilities alone affect 5-10% of children in public schools ADHD conservatively affects 3-8% of all school children; CDC reported 7.8% in 2003 (ages 4-17) Marked increase in autism spectrum disorders not fully explained by changes in diagnostic criteria or increased reporting 6

7 Lead, alcohol, nicotine Alcohol hyperactivity, cognitive deficits Nicotine IQ deficit, learning and attention deficits Lead impaired IQ, learning, attention; hyperactivity, impulsiveness, aggression; failure to complete school, trouble with the law (males more susceptible to behavioral effects; steeper drop in cognition at lower levels) Tobacco plus lead: 8 fold increase in ADHD risk Lead Cumulative occupational exposure cognitive impairment Shih x risk Parkinson s Coon 2006 Cumulative community exposure cognitive impairment Shih 2006 Up to 15 years inc. cognitive aging (MMSE) Weisskopf 2004 Impacts are greater in people living in stressful neighborhood Glass, 2009 Animal studies of early life exposure Rodents: Late-life Alzheimer s markers: amyloid precursor protein, amyloid B (Basha 2005, Lahiri 2007) Primates: same plus plaques (Wu, J Neurosci, 2008) 7

8 Additional neurodevelopmental hazards Methylmercury Polychlorinated biphenyls (PCBs) Pesticides e.g. organophosphates Brominated flame retardants Perchlorate Organic solvents (in addition to ethanol) Arsenic, manganese Etc. Pesticides and Parkinson s disease Human studies - 24/31 studies show risks for PD. (OR 1.6-7); positive dose-response where examined (Brown 2006) Animals -Rotenone & paraquat damage neurons in striatal region of brain - Combinations of maneb and paraquat; - prenatal exposure primes the brain, increasing adult susceptibility (Cory-Slechta 2005) 8

9 Developmental neurotoxicity of industrial chemicals: the known, unknown-unstudied universe Lead Methylmercury Arsenic PCBs Solvents Pesticides Manganese Fluoride Perchlorate Brominated flame retardants Grandjean, Lancet, 2006 Air pollution Particulates; nitrogen oxides; SO2; hazardous chemicals; metals; CO2 Particulates > increased risk of respiratory illnesses, premature death from coronary artery disease SO2 > asthma NOx > ozone; smog precursors; green house gas CO2 > green house gas 9

10 Climate change and public health More heat-related illness Greater risk of infectious disease Worsening air quality Threatened quality and quantity of water Rising sea levels; community displacement More extreme weather events Threatened food supplies; food safety Environmental refugees; security concerns Stressed ecosystems; loss of services 10

11 Food environment High glycemic carbohydrates increase the risk of diabetes, CHD, obesity High glycemic carbohydrates break down quickly during digestion, rapidly releasing glucose (sugar) into the bloodstream. INSULINEMIC RESPONSE Δ Plasma In nsulin,mg/dl Low glycemic food High glycemic food Time, mins 11

12 Properties of Fatty Acids Omega-3 Omega-6 Saturated Food System Immune Properties Perishable Durable Increased in Short shelf life Processed foods factory farmed Increased in Long shelf life animals pasture-fed animals Anti-inflammatory inflammatory Inflammatory & Inflammatory Anti-inflammatoryinflammatory Evolutionary Context Recent marked decline Recent marked increase Recent marked increase 12

13 Influence of nutritional factors on chronic diseases Increase risks saturated and trans fats high glycemic carbohydrates lack of fruits/vegetables/omega 3s Large excess omega 6s vs. omega 3s Reduce risks fruits, vegetables omega 3s (fish, pasture-fed animals, walnuts, flax) low glycemic carbohydrates Mediterranean diet Benefits of Mediterranean-Type Diet on Chronic Disease Risk Clinical intervention studies 70% heart attacks, cardiac death & total mortality DeLogeril 60% cardiac events in CVD patients* Ornish 98 ~50% metabolic syndrome Esposito 04 39% in CRP Esposito 04 insulin resistance Esposito 04 weight Esposito 04 DeLogeril 94 Prospective observation studies 80% diabetes Martinez-Gonzalez 08 ~31% all-cause & cardiovascular mortality, 22% cancer mortality*calculated from Sofi 08* 73% Alzheimer s mortality Scarmeas % Parkinson s disease Gao 07 78% childhood asthma maternal diet Chatzi 08 *10% low fat, vegetarian diet + exercise, stress reduction; social support 13

14 Socioeconomic, Psychosocial Stressors Lower socioeconomic status risk of impaired neurodevelopment, cardiovascular disease, diabetes, obesity, metabolic syndrome, Alzheimer s disease, many kinds of cancer, asthma. urces.php Due to: Combinations of increased exposures to hazards, increased susceptibility, decreased capacity to cope and recover. Elevated levels of inflammatory cytokines, glucocorticoids, sympathetic activity Effects of the Built Environment on Health Neighborhoods that lack social cohesion, sidewalks, or safety Limited exercise Increased risk of depression and obesity Increased impact of other stressors (e.g. lead) Health effects of indoor and outdoor air contaminants 14

15 The challenges inherent in putting it all together Cumulative risk of chemical and non-chemical stressors Science and Decisions: Advancing Risk Assessment 2009 The framework for risk assessment of chemicals should be modified to account for uncertainty and variability in responses to exposures attributable to age, ethnic group, and socioeconomic status, as well as other attributes that affect individuals and make them a part of a vulnerable group. 15

16 Environmental Threats to Healthy Aging Environmental Factors Food system/diet Toxic Chemicals Environmental contaminants Socioeconomic stressors Altered Pathways Inflammation Oxidative Stress Disrupted Insulin Signaling Endocrine disruption Diabetes Cardiovascular disease Obesity Abnormal lipids Metabolic syndrome Alzheimer s Environment Drives Chronic Disease Environmental Factors Altered Pathways Chronic Disease Mechanisms of Action Inflammation Disrupted Insulin Signaling Oxidative Stress 16

17 Inflammation Inflammation is a dimension of diabetes, metabolic syndrome, obesity, CVD, some neurodegenerative disorders, and other chronic illnesses. Numerous inflammatory markers involved Sources of oxidative stress Food Tobacco smoke Industrial pollutants Ozone, particulate air pollution Pesticides id Organic solvents Some pharmaceuticals 17

18 Insulin Signaling = Normal Metabolism Insulin signaling blood sugar artery compliance triglycerides Disrupted Insulin Signaling = Inflammatory Metabolism Inflammation Oxidative stress Insulin signaling blood sugar artery stiffness triglycerides 18

19 Environmental Factors Disrupt Insulin Signaling, Drive Inflammatory Metabolism Stress Saturated fat Omega-3 Obesity Inactivity Inflammation Oxidative stress Antioxidants Other industrial chemicals Air Pollution Insulin signaling blood sugar artery disease triglycerides Lead, other heavy metals Some Pesticides High Glycemic Carbohydrates Fructose Solutions for Healthy People & A Healthy Planet 19

20 Responses Research agenda (Children s Health Study; innovative study design and data analysis) Personal Community Sectoral: health care; agriculture, material/product manufacturing, education, etc. Improved risk assessments and regulations Cross-cutting solutions Major Illnesses Are Preventable Personal Actions to Reduce Risks Personal Level Approaches to Healthy Living Eat healthy whole, fresh, unprocessed, primarily plant based foods; not too much Avoid toxicants whenever possible Exercise Be socially engaged 20

21 Clinicians: Environmental history CH2OPS Community Home/hobbies Occupation (school for children) Personal Socioeconomic i Diet, exercise, toxic exposures..home, hobbies, work, school, community; personal habits, etc Current system: Food, agriculture Subsidies poorly aligned with health goals; Not sustainable: depends on cheap energy, abundant water, climate stability contributes significantly to environmental degradation air and water pollution; marine dead zones Greenhouse gases > climate change 21

22 Food, agriculture Sustainable, nutritious food production ; Reduced use of pesticides; synthetic fertilizers Healthier food Improved food access Opportunities for health care Local purchasing > local economic support Modeling behavior for other sectors Farm bill: reform in ways that more closely align subsidies and goals with health-based dietary guidance Chemicals, products Institutional preferential purchasing Request product chemistry data from suppliers Prioritize chemicals of high concern for phase out Create contractual obligations with suppliers Avoid chemicals of high concern; safer alternatives Develop goals and metrics to measure progress Communicate rationale to employees, patients, community 22

23 Chemicals, products Support reform of 1976 Toxic Substances Control Act (TSCA; Federal statute) --the most egregious example of ineffective regulation of environmental chemicals --the President s Cancer Panel H.R The Toxic Chemicals Safety Act The built environment Transportation Mass transit linked to sidewalks and bike paths (increased exercise, less air pollution, GHG) Parks, recreation, safe neighborhoods Health care: Green building; transportation policies; reduced energy consumption Support energy policy reform Climate change, air pollution 23

24 Conclusion Causes of prevalent diseases and causes of environmental degradation have much in common Common drivers; common solutions Many opportunities to intervene can help to solve multiple problems What is our responsibility for primary prevention? The level of our commitment? Acknowledgements; resources Environmental Threats to Healthy Aging Jill Stein, Maria Valenti, Ben Rohrer Science and Environmental Health Network Health Care Without Harm Collaborative on Health and Environment 24